CDC AND INDIAN COUNTRY 

WORKING TOGETHER
6
CDC and Indian Country

Working Together

Contents

Welcome and Introduction ................................................................................................... 1

CDC’s Mission....................................................................................................................... 2

CDC’s Role............................................................................................................................ 3

Health in Indian Country ....................................................................................................... 4

Detecting and Responding to New and Emerging Health Threats ......................................... 6

Tackling the Biggest Health Problems Causing Disability and Death...................................... 8

Putting Science and Advanced Technology into Action to Prevent Disease .......................... 10

Promoting Healthy and Safe Behaviors, Communities, and Environments .......................... 12

Developing Leaders and Training the Public Health Workforce, 

Including Disease Detectives .............................................................................................. 16

Taking the Health Pulse of Our Nation................................................................................. 20

What’s Ahead ..................................................................................................................... 24

CDC Visits in Indian Country: A Snapshot............................................................................. 28

Centers for Disease Control and Prevention

1600 Clifton Road 

Atlanta, GA 30329-4027 USA 

800-CDC-INFO (800-232-4636), TTY: 888-232-6348

Contact CDC-INFO: www.cdc.gov/contact

Centers for Disease Control and Prevention. CDC and Indian Country Working Together. Atlanta, GA: Centers for Disease 

Control and Prevention, US Dept of Health and Human Services; 2017.

Welcome and Introduction

Welcome to the Centers for Disease Control 

and Prevention (CDC) and a snapshot of CDC’s 

work in Indian Country, with tribal nations, 

tribal organizations, and American Indians and 

Alaska Natives across the United States.

CDC’s Tribal Advisory Committee (TAC) 

asked CDC to prepare a booklet describing 

our organization and the work we do in Indian 

Country as part of our broad portfolio to 

improve health and protect against health 

threats here at home and around the world.

The TAC advises CDC/ATSDR (Agency for 

Toxic Substances and Disease Registry) 

on policy issues and broad strategies that 

may significantly affect American Indian 

and Alaska Native communities. The TAC 

collaborates with CDC/ATSDR in fulfilling 

its mission to promote health and quality of 

life by preventing and controlling disease, 

injury, and disability through established 

and ongoing relationships and consultation 

sessions. The TAC consists of 16 voluntary 

representatives: 1 delegate (and 1 authorized 

representative) from a federally recognized 

tribe geographically located in each of the 12 

Indian Health Service Areas, and 1 delegate 

(and 1 authorized representative) from 4 

federally recognized tribes-at-large. The TAC 

convenes twice each year, during the winter 

at CDC headquarters and during the summer 

hosted by a tribal nation.

CDC is pleased to provide this report to our 

TAC and to offer you, our reader, a glimpse 

of the work we do, the accomplishments we 

have shared together, and the opportunities 

we have in the future to create even stronger 

bonds and deeper collaborations in the service 

of health and wellness for all. 

Summer 2015 Tribal Advisory Committee Meeting, Airway Heights, WA: Robert Flying Hawk (Great Plains Area), 

Kate Grismala (Nashville Area), Beverly Coho (Albuquerque Area), Chester Antone, TAC Chair (Tucson Area), 

Jonathan Nez (Navajo Area), Darcy Morrow (Tribes-at-Large), Cathy Abramson (Bemidji Area), 

Shawna M. Shillal-Gavin (Portland Area) , Andy Joseph (Tribe-at-Large), and Adam Geisler (California Area).

1
CDC’s Mission 

CDC works 24/7 to protect America from health, 

safety and security threats, both foreign and 

in the United States. Whether diseases start at 

home or abroad, are chronic or acute, curable or 

preventable, human error or deliberate attack, 

CDC fights disease and supports communities 

and residents to do the same.

CDC increases the health security of our nation. 

As the nation’s health protection agency, CDC 

saves lives and protects people from health 

threats. To accomplish our mission, CDC 

conducts critical science and provides health 

information that protect our nation against 

expensive and dangerous health threats, and 

responds when these arise.

With an approximate annual budget of 

$12 billion, including the Vaccines for Children 

program, and more than 14,000 staff, CDC 

supports communities throughout the United 

States and protects Americans by working 

in more than 60 countries around the world. 

Almost 85% of CDC’s domestic funding is 

provided directly to state, tribal, local, and 

territorial entities to detect and control disease, 

prevent the leading causes of death, and prepare 

for health threats.

What is ATSDR? The Agency for Toxic 

Substances and Disease Registry (ATSDR), 

co-located with CDC in Atlanta, Georgia, is a 

federal public health agency like CDC. ATSDR 

serves the public by using the best science, 

taking responsive public health actions, and 

providing trusted health information to prevent 

harmful exposures and diseases related to 

toxic substances. The Director of CDC is the 

Administrator of ATSDR. 

2
CDC’s Role 

As the lead public health agency in the United 

States, CDC helps save lives by responding to 

emergencies, providing public health expertise, 

developing vaccines, and detecting disease 

outbreaks wherever they arise. CDC works to 

strengthen state, tribal, local, and territorial 

health departments; helps promote health 

programs that are proven to work; informs 

decision makers about public health science 

and effective action; and provides people with 

information they need to take charge of their 

health. CDC’s scientists collect and analyze data 

to monitor health threats, find solutions to health 

problems, and reduce their impact on people’s 

lives. Our work has protected people from 

hundreds of public health threats every year.

CDC supports the nation, including tribal 

nations, in six areas: 

• Detecting and responding to new and 

emerging health threats. 

• Tackling the biggest health problems 

causing death and disability. 

• Putting science and advanced technology 

into action to prevent disease. 

• Promoting healthy and safe behaviors, 

communities and environments. 

• Developing leaders and training the 

public health workforce, including 

disease detectives.

• Taking the health pulse of our nation.

Turn the pages of this report to learn more 

about CDC’s work in Indian Country in each 

of these areas.

FAST FACTS ABOUT CDC

• Established in 1946 and 

headquartered in Atlanta, GA. 

• CDC’s Budget in FY 2016: $7.2 

billion, plus $4.1 billion for the 

Vaccines for Children program. 

• More than 14,000 employees 

in nearly 170 occupations. 

• The CDC Director is appointed 

by the Secretary of the US 

Department of Health and 

Human Services, who is 

appointed by the President.

• Field staff work in all 50 states 

and more than 60 countries. 

• CDC is one of a dozen major 

operating divisions within the 

US Department of Health and 

Human Services, a federal 

executive department. 

3
Health in Indian Country

American Indians and Alaska Natives are as diverse as the 

places they come from, with unique cultures, languages, 

histories, arts, and practices. Yet all share a deep connection to 

lifeways that can sustain health and wellness. American Indians 

and Alaska Natives have persevered and sustained themselves 

and much of their cultures, in spite of fraught relationships with 

the US government that have compromised lifeways, culture, 

and health and wellness. Today, American Indians and Alaska 

Natives have higher rates of disease, injury, and premature 

death than other racial and ethnic groups in the United States. 

Many Native populations also have higher rates of poverty, 

unemployment, poor housing, and low education, among 

other adversities. These afflictions result from historical insults 

and injustices, perpetrated over many generations, including 

massacres, genocidal policies, epidemics from introduced 

diseases, forced relocations, removal of children through 

boarding school policies, and prohibition of spiritual and 

cultural practices (including use of Native languages). 

CDC works with and supports 

American Indian tribes, 

Alaska Native villages, tribal 

organizations, and Tribal 

Epidemiology Centers to promote 

health, prevent disease, reduce 

health disparities, and strengthen 

connections to culture and 

lifeways that improve health 

and wellness that have been 

threatened over generations. 

CDC’s work with and support of 

Indian Country to improve the 

lives of Native peoples is reflected 

in this report. 

San Carlos Apache Tribe

4
Some of the health and socioeconomic disparities that face

American Indians and Alaska Natives include: 

• American Indians and Alaska Natives born 

today have a life expectancy that is 4.4 years 

less than all US races (73.7 years to 78.1 years, 

respectively). 

• American Indians and Alaska Natives have 

the second highest infant mortality rate after 

non-Hispanic blacks. 

• American Indians and Alaska Natives have the 

highest prevalence of diabetes in the United 

States, more than twice the prevalence of 

diabetes among non-Hispanic whites. 

• American Indians and Alaska Natives have 

higher infectious disease death rates than 

non-Hispanic whites. 

 Some of the greatest infectious disease 

death rate disparities are found in remote 

and isolated regions of the United States, 

including Alaska, the Northern Plains, and 

Southwest regions. Remoteness, isolation, 

lack of adequate sanitation, and other 

factors contribute to these disparities. 

 Incidence rates of 14 of 26 notifiable 

infectious diseases were higher for 

American Indians and Alaska Natives 

compared to non-Hispanic whites. 

• American Indian and Alaska Native youth 

and adults have the highest prevalence of 

commercial cigarette smoking among all racial 

or ethnic groups in the United States. 

 Cigarette smoking varies widely by region, 

with lower prevalence in the Southwest and 

higher prevalence in the Northern Plains 

and Alaska. 

 American Indians and Alaska Natives have 

the lowest rate of cigarette smoking quit 

attempts among all racial or ethnic groups 

in the United States.

• American Indian and Alaska Native adults 

are 50% more likely to have obesity than 

non-Hispanic white adults. 

• American Indians and Alaska Natives have the 

highest percentage of current heavy alcohol 

users compared to other racial and ethnic 

groups in the United States.

• The suicide rate among American Indian and 

Alaska Native adolescents and young adults 

ages 15 to 34 is 1.5 times higher than the 

national average for that age group.

• Motor vehicle crashes are a leading cause 

of unintentional injury for American Indians 

and Alaska Natives ages 1 to 44. American 

Indian and Alaska Native adults are 1.5 times 

more likely to die in a crash than white or black 

Americans. 

• More than 26% of American Indians and Alaska 

Natives lived in poverty in 2015, the highest 

rate of any racial group. For the nation as a 

whole, the poverty rate was 14.7%. 

• The American Indian and Alaska Native high 

school graduation rate is 67%, the lowest of any 

racial or ethnic group across all US schools. 

Despite historical and other 

traumas, American Indians and 

Alaska Natives—and much of 

their cultures, languages, and 

practices —have survived. During 

the 20th and 21st centuries, 

American Indians and Alaska 

Natives rebuilt their nations, 

adapted to cultural and economic 

pressures and opportunities, 

overcame adverse and destructive 

policies, and today are a growing, 

dynamic and resurgent part of the 

United States.

5
Detecting and Responding to New 

and Emerging Health Threats

Whether fighting Ebola in West Africa, 

Legionnaire’s Disease in Pennsylvania, or Rocky 

Mountain Spotted Fever (RMSF) in Arizona, 

CDC’s scientists and disease detectives help find 

the source of the problem and support action 

to stop the threat. Often a known threat, like 

hepatitis C virus (HCV) or even obesity, emerge 

at a higher rate than usual and require new 

efforts and insights to be brought under control. 

Here are two examples of CDC in action in 

Indian Country, providing support to detect and 

respond to new and emerging health threats.

pRocky Mountain Spotted Fever (RMSF) is a 

potentially fatal tickborne disease. From 2003 to 

2014, more than 300 cases, including 20 deaths, 

were reported by tribal communities in Arizona. 

The rate of RMSF on the three most highly 

affected American Indian reservations in rural 

Arizona was more than 150 times the national 

rate. In 2012, CDC began working with one 

highly affected tribe, along with federal, state, 

tribal, and private partners on a new prevention 

program to decrease the incidence of RMSF. The 

approach included applying pesticide sprays 

around yards, placing long-acting tick collars on 

every dog in the area, and offering free spay and 

neuter services to curb the dog population. The 

tribe took these strategies community-wide, 

tackling ticks in every home. These joint efforts 

decreased RMSF incidence by 43%. This project 

has guided best practices for other tribal and 

international communities suffering from RMSF.

pSince 1999, CDC has collaborated with 

partners to identify and characterize health 

issues linked to environmental exposures in 

Indian Country. CDC’s work with tribes has 

addressed a number of sources, routes, and 

types of exposures, including exposures to 

chemicals from drinking water and seafood. 

For example, in collaboration with the Cheyenne 

River Sioux Tribe, CDC quantified bisphenol A 

and arsenic concentrations in people living on 

the Cheyenne River Sioux Tribe reservation. 

Researchers looked at associations between 

these environmental chemicals and diabetes 

mellitus. A separate study with the tribe aimed 

to quantify mercury exposure among residents 

of the reservation who ate at least two servings 

of locally caught fish per week from waters with 

high mercury levels. 

Navajo Nation

6
Confederated Tribes of the Umatilla Indian Reservation

pCherokee Nation health officials estimate 

that 6% of adults are infected with the hepatitis 

C virus (HCV), six times the US rate. The 

Cherokee Nation requested CDC support to 

develop an HCV prevention and testing program 

that would link Cherokee adults to care and 

treatment. Eager to address the problem, 

the Cherokee Nation started the project to 

strengthen care and move toward eliminating 

HCV among American Indians served by the 

Cherokee Nation Health System. CDC joined in, 

providing extensive technical assistance. 

This project will improve the health of the 

Cherokee Nation and also help design similar 

programs that other tribal nations can use 

to move toward eliminating HCV infection. 

With additional support from the Oklahoma 

Department of Health, university physicians, 

and private partners, the Cherokee Nation 

increased first-time testing for HCV fivefold, 

and more than doubled HCV treatment among 

Cherokee Nation members. 

7
Tackling the Biggest Health 

Problems Causing Death and 

Disability

For Americans Indians and Alaska 

Natives, as well as for Americans 

in general, the leading causes 

of death and disability are heart 

disease, cancer, injuries (including 

motor vehicle injuries and suicide), 

respiratory diseases, and diabetes. 

CDC tackles these diseases at their 

source, including commercial tobacco 

use, poor nutrition, lack of physical 

activity, and excessive alcohol use. 

CDC favors a proven approach that 

supports communities to help make 

healthy choices easy and accessible 

to people.

pGood Health and Wellness 

in Indian Country (GHWIC) is CDC’s largest 

single investment in Indian Country. This 5-year 

program, funded at $16 million in 2015, supports 

a coordinated, holistic approach to healthy living 

and chronic disease prevention and supports 

and reinforces work already underway in Indian 

Country to make healthy choices and lifeways 

easier for American Indians and Alaska Natives. 

The program seeks to reduce disability and 

death due to commercial tobacco use, obesity, 

diabetes, heart disease, and stroke. Twelve 

tribes, 11 tribal organizations, and 11 Tribal 

Epidemiology Centers (TECs) use communitychosen and culturally tailored approaches to 

improve policies, systems, and environments 

in support of healthy choices and behaviors. 

The 11 tribal organizations provide leadership, 

technical assistance, and resources to more than 

100 other tribes and tribal organizations in their 

Indian Health Service (IHS) areas. The 11 TECs 

serve tribes, villages, and tribal organizations to 

evaluate approaches and show impact. One TEC, 

the Urban Indian Health Institute, coordinates 

the national evaluation by providing support and 

expertise to other TECs, tribal organizations, 

tribes, and CDC.

pCompared to the US population as a 

whole, American Indians and Alaska Natives 

have suffered more often from many vaccinepreventable diseases. The federally funded 

Vaccines For Children (VFC) program provides 

vaccines at no cost to eligible children under 19 

years of age. All American Indian and Alaska 

Native children are eligible for VFC vaccines. 

San Carlos Apache Tribe

8
Most IHS and tribal health care facilities are 

enrolled in the program and receive free 

vaccines from their state immunization 

programs. VFC has contributed to high 

immunization coverage for American Indian 

and Alaska Native children and adolescents, and 

these children are no longer getting diseases 

at higher rates. For example, the human 

papillomavirus (HPV) vaccine helps prevent 

certain cancers. In 2015, coverage with at 

least one dose of HPV vaccine was 84.4% for 

American Indian and Alaska Native girls aged 

13–17 years seen in IHS-funded clinics compared 

to 62.8% for the general US adolescent 

population and 79.4% among boys compared to 

49.8% for other US boys. 

pCDC’s Sexually Transmitted Disease 

(STD) Prevention Program partnered with 

the Association of American Indian Physicians 

(AAIP), the National Indian Women’s Health 

Resource Center (NIWHRC), and the Gila River 

Indian Community to develop and implement 

culturally adapted community interventions 

for adolescents to prevent STDs, including 

HIV, as well as teen pregnancies, on Gila River. 

NIWHRC provided the “Becoming a Responsible 

Teen” (B.A.R.T.) course to 500 students. The 

course taught about understanding HIV and 

AIDS, assertive communication skills, decision 

making, contraception use, condom use, 

planning for the future, and how to use this 

information in your daily life. The Gila River 

Indian Community then provided STD/HIV 

prevention education to 700 American Indian 

adolescents and adults in 26 different locations 

throughout Arizona. Through partnerships with 

NIWHRC and Gila River Indian Community, 

AAIP developed information and tools for 

others to use. 

pCDC’s National Breast and Cervical Cancer 

Early Detection Program provides low-income, 

uninsured, and underserved women access 

to timely breast and cervical cancer screening 

and diagnostic services. During 2012–2017, 

CDC supported 11 American Indian and Alaska 

Native tribes, and tribal organizations to 

provide these services. For example, for 20 

years, the Navajo Nation Breast and Cervical 

Cancer Prevention Program has been providing 

breast and cervical cancer screening services to 

women living on or near the Navajo Reservation. 

The program hosts mobile mammography 

events and coordinates appointments with local 

IHS and 638 facilities in five service units on the 

Arizona side of the Navajo Nation. In 2016, the 

program organized their first event reaching 

Navajo women in New Mexico.

9
Putting Science and Advanced 

Technology into Action to 

Prevent Disease

CDC scientists are among the best in the world. They track diseases and find out what is 

making people sick and the most effective ways to prevent it. Using cutting-edge technology, 

they confront global disease threats through advanced computing and lab analysis of huge 

amounts of data to quickly find solutions to the most pressing public health problems.

pFor more than 40 years, CDC’s Arctic 

Investigations Program (AIP) has collaborated 

with the Alaska Native Tribal Health 

Consortium, the state of Alaska, and other 

partners to tackle infectious disease threats 

using state-of-the-art laboratory diagnostics, 

epidemiology, outbreak investigations, and 

targeted research. AIP helps everyone living 

in Alaska enjoy healthier and longer lives by 

focusing on reducing and preventing infectious 

diseases that are more likely to affect American 

Indians and Alaska Natives. AIP works closely 

with Alaska tribal organizations to respond to 

health problems—such as skin infections, dental cavities in children, high rates of respiratory 

infections (including pandemic influenza), and the impact of climate change on health. AIP 

also helps support tribal groups with evaluations of infectious disease prevention and control 

programs, such as immunizations. AIP works closely with IHS to document and track health 

problems over time to chart progress and areas where improvement is needed. 

For example, after introduction of effective vaccines against two severe bacterial infections 

(Hib and pneumococcus), AIP researchers documented a 95% decline in these vaccinepreventable diseases in infants and children. However, AIP surveillance also detected the 

emergence of new types of bacteria not covered by these vaccines. In 2009, AIP researchers, 

along with tribal health partners introduced a new vaccine against pneumococcus in parts of 

rural Alaska with the highest rates. Today, with routine use of that vaccine throughout Alaska, 

infection rates are lower than they have ever been, and the difference in rates between Alaska 

Natives and other Alaska children has been substantially reduced.

10
pHepatitis B and A were endemic in Alaska 

until vaccines for these viruses were licensed 

in 1981 and 1996, respectively. As a result 

of high vaccine coverage in Alaska, rates of 

hepatitis B and A infection have plummeted, 

and transmission of hepatitis B virus from 

mother to baby is rare. However, questions 

remain about the long-term effectiveness of 

the hepatitis B vaccine and whether vaccinated 

persons require booster doses to maintain 

protection against infection in the future. 

These questions are particularly important 

for those who received hepatitis B vaccination 

at birth. Because Alaska was one of the first 

areas in the world to implement large-scale 

hepatitis B and A vaccine programs, CDC and 

the Alaska Native Tribal Health Consortium 

are collaborating to answer these questions 

and add booster doses if they are needed to 

maintain immunity. 

The Alaska Native Tribal Health Consortium 

(ANTHC) provides care to many people with 

chronic hepatitis B and hepatitis C infection. 

These persons are followed through the ANTHC 

Liver Disease and Viral Hepatitis Program, 

which provides expert clinical care and conducts 

research to prevent illness from these infections.

This program is one of the few in the world with 

the capability to conduct studies of the long-term 

immunity and effectiveness of hepatitis B and C vaccines. For example, 

a follow-up of some of the first people in the world who were vaccinated 

against hepatitis B was completed and shows that over 90% are still 

protected 30 years after receiving the vaccine. CDC participates in this work 

by providing technical expertise and financial support from its Viral Hepatitis 

and Arctic Investigations Programs.

Cherokee Nation

11
Promoting Healthy 

and Safe Behaviors, 

Communities, and 

Environments

Health and wellness are influenced by the places in 

which people live, learn, work, and play and the support 

people have in their communities to take charge of their 

health. Communities, including homes, schools, public 

spaces, and worksites, can support well-being and make 

healthy choices easy and affordable for people. Healthy 

and safe community environments include clean air 

and water, affordable and secure housing, sustainable 

and economically vital neighborhoods, and supportive 

structures, such as places to be active and access to 

affordable healthy foods. CDC promotes healthy and 

safe behaviors, communities, and environments through 

grant programs that foster collaborations among diverse 

sectors—like housing, health care, transportation, 

education, and agriculture—and support community 

health needs assessments to develop community health 

improvement plans. pIn partnership with CDC, the Red Cliff Band of Lake 

Superior Chippewa partnered with the Great Lakes 

Inter-Tribal Epidemiology Center to conduct surveys to 

better understand the needs of their people. Red Cliff 

will use tools and resources from CDC’s GHWIC program 

to analyze and understand the data and make decisions 

about programs in the community. Red Cliff is the first 

tribe in the Bemidji Area to complete a Tribal Behavioral 

Risk Factor Survey and put their community information 

into action to improve health. pAnother GHWIC grantee, the Albuquerque Area 

Southwest Tribal Epidemiology Center, partners with 

12
the University of New Mexico’s Project ECHO

to train tribal community health representatives 

(CHRs), in the 27 Albuquerque Area Tribes to 

help tribal members prevent and manage type 2 

diabetes, heart disease, stroke, and associated 

risk factors. The training is offered to as many 

as 25 tribal members twice a year, training up 

to 200 CHRs, who will work with community 

members with or at risk of chronic diseases to 

reduce their risks and improve their health. 

pAt the request of the Tohono O’odham 

Nation and the US Environmental Protection 

Agency (EPA), ATSDR investigated public 

health risks associated with the Cyprus Tohono 

Corporation Mine, an EPA Superfund Alternative 

Site on the Tohono O’odham Nation reservation. 

The Tribe had concerns about water and air 

quality and biocontamination of plants and 

animals that the community hunts and gathers. 

ATSDR visited the mine site, met with Tribal 

government officials and community members, 

and gathered and reviewed site documents 

and data. In February 2016, ATSDR published 

a health consultation report and summary fact 

sheet with its findings and recommendations. 

pCDC’s Tribal Motor Vehicle Injury 

Prevention Program (TMVIPP) provided grant 

support to 12 tribes and helped to decrease 

crashes, increase restraint use (such as seat 

belts and car seats), and decrease alcoholimpaired driving. In an effort to reach more 

tribes, CDC partnered with the Federal Highway 

Administration’s Tribal Technical Assistance 

Program to implement TMVIPP best practices. 

This partnership allows CDC to fund technical 

support, training, and other activities to reduce 

motor vehicle-related fatalities and injuries in 

Indian Country and reach up to 37% of federally 

recognized tribes. 

pCDC partnered with IHS to develop the 

Roadway to Safer Tribal Communities 

Toolkit, which includes fact sheets, posters, 

and a video to help prevent crash-related 

injuries and deaths among members of tribal 

nations. CDC and its partners have also shared 

the Tribal Motor Vehicle Injury Prevention 

(TMVIP) Best Practices Guide, which includes 

effective strategies, lessons learned from 

federal programs, and essential components of 

successful tribal traffic safety programs.

13
pWith CDC and IHS assistance, the San 

Carlos Apache Tribal Motor Vehicle Injury 

Prevention Program reduced alcohol-impaired 

driving and increased use of seat belts and 

child safety seats among Tribal members. The 

campaign, which included media, education, 

and enforcement, led to a 52% increase in the 

number of impaired driving arrests, lowered the 

legal limit for presumptive impairment from 

.10 to .08 blood alcohol level, and put in place a 

primary seat belt law. During the program, the 

Tribe saved $2.7 million. For every $1 spent, a 

lifetime benefit of almost $10 was saved from 

reductions in road crashes.

pThe Hopi Tribe used CDC funding to 

improve collaboration with law enforcement 

to strengthen their existing seat belt law. A 

successful media campaign raised awareness 

among Tribal members about the importance 

of buckling up. The campaign, educational 

efforts, and improved enforcement led to a 36% 

increase in seat belt use and a 32% increase in 

the use of child safety seats. 

pThe MENU-AIDDS Health Promotion 

Program provides dietary recommendations, 

such as the Dietary Guidelines for Americans, 

to help people with intellectual and developmental disabilities and their supporters 

serve healthy, nutritious meals. More than 

160 community group homes for adults with 

intellectual and developmental disabilities have 

been trained to implement MENU-AIDDS. 

For example, the group home manager at 

Eastern Montana Industries, located near the 

Crow and Northern Cheyenne Nations, used 

the Menu-AIDDS program to improve meals 

by learning about traditional native vegetables 

and increasing resident involvement in menu 

planning. Residents and staff learned new 

recipes together and native foods were offered 

at meals. 

pThe Standing Rock Sioux Tribe’s Native 

Gardens Project, funded through CDC’s 

Traditional Foods Program, increased access to 

local traditional foods and awareness about the 

availability and health benefits of harvesting 

and eating these foods. During the 3-year grant, 

the project collaborated with local farmers, the 

US Department of Agriculture’s (USDA’s) 

Nutrition for the Elderly program, the Tribe’s 

Special Diabetes Program, and the County 

Extension Service to hold 61 farmers’ market 

days, serving an estimated 2,500 people. 

Almost 13,000 farmers’ market vouchers ($50 

value each) were distributed as part of the 

USDA program to 1,193 elders, who exchanged 

their vouchers for produce at the markets. 

pSuicide is the second leading cause of death 

among American Indians and Alaska Natives 

aged 15 to 34 years and the eighth leading 

cause of death across all American Indian and 

Alaska Native age groups. In collaboration 

with IHS, CDC’s Injury Prevention Program 

works to reduce intentional and unintentional 

injuries, including suicide. Three TECs are 

cataloging suicide prevention resources to 

effectively reduce the burden of suicide and 

the potential for suicide clustering, especially 

among young people. CDC also works with 

IHS to support one of the few evidencebased suicide prevention programs for tribes. 

Formerly called Natural Helpers, the Model 

Adolescent Suicide Prevention Program is 

included in the National Registry of Evidencebased Programs and Policies.

14
Confederated Tribes of the Umatilla Indian Reservation

It’s good to see that 

CDC is learning from 

Indian Country.

“

”
Developing Leaders and Training 

the Public Health Workforce, 

Including Disease Detectives

CDC supports numerous training and 

outreach programs to develop public health 

leaders and strengthen the public health 

workforce. Our premier training program 

is the Epidemic Intelligence Service (EIS), 

developing field epidemiology skills and 

expertise in physicians, veterinarians, 

nurses, scientists, and other public health 

professions. CDC also provides training and 

workforce development through our public 

health grant programs. These and other 

efforts nurture public health professionals 

and help sustain strong, well-resourced 

public health leadership and capabilities 

at the national, state, tribal, local, and 

territorial levels. 

An Epi-Aid is a way for Tribal Nations and 

other public health authorities to request 

the short-term 

epidemiologic 

assistance of 

CDC’s EIS Officers 

to respond to 

an urgent public 

health problem. In 

addition to sending 

experts to help address a public health 

problem, Epi-Aids are a way to strengthen 

the skills and expertise of health leaders in 

the community. CDC supported 13 Epi-Aids 

to tribal areas in the past 5 years, involving 

34 EIS Officers.

• Epi-Aid 2016-031: Undetermined transmission and 

risk factors for multidrug-resistant tuberculosis 

among tribal members—Arizona, 2016 

(5 EIS Officers).

• Epi-Aid 2016-044: Assessment of substance 

use during pregnancy—Northern Plains Tribal 

Epidemiology Center, 2016 (4 EIS Officers).

• Epi-Aid 2014-001: Investigation of a fatal case of 

Rocky Mountain Spotted Fever on an American 

Indian reservation in eastern Arizona 

(3 EIS Officers).

• Epi-Aid 2014-008: Increases in gonorrhea 

cases among American Indians in Arizona 

(4 EIS Officers).

• Epi-Aid 2014-042: Identification of undetermined 

risk factors for exposure in a syphilis outbreak 

among American Indians—Reservation X, 

multistate, 2014 (2 EIS Officers).

• Epi-Aid 2013-018: Tuberculosis outbreak among 

American Indians (1 EIS Officer).

• Epi-Aid 2013-035: Group A Streptococcal disease 

among Navajo Nation citizens of Apache County, 

Arizona (3 EIS Officers).

• Epi-Aid 2013-057: Healthy nutrition in Navajo 

Nation stores (3 EIS Officers).

• Epi-Aid 2012-047: Assessment of risk for Rocky 

Mountain Spotted Fever (RMSF) in an Arizona 

Indian tribe (2 EIS Officers).

• Epi-Aid 2012-051: Assessment of increased rates 

of chlamydia and gonorrhea among American 

Indians (1 EIS Officer).

• Epi-Aid 2012-058: Assessment of risk for Rocky 

Mountain Spotted Fever (RMSF) in an Indian tribe 

(2 EIS Officers).

• Epi-Aid 2012-066: Evaluation of a Rocky Mountain 

Spotted Fever (RMSF) Prevention Program 

(2 EIS Officers).

• Epi-Aid 2011-067: Investigation of increased 

number of tuberculosis cases among American 

Indians (2 EIS Officers).

16
“I am from western 

Navajo. When I say people are 

scared, they are scared, especially 

after someone has died from the 

hantavirus...We are working with the 

experts and our dialogue in Atlanta 

will go a long way toward these 

prevention efforts.” 

Navajo Nation

Disease detectives at work

In January 2016, a child from western Navajo Nation died of complications from 

hantavirus, prompting Navajo officials to meet with officials from CDC about public 

outreach, awareness, and prevention of hantavirus. Hantavirus 

infection can progress to hantavirus disease, fatal in 

about 38% of cases. CDC experts and leaders 

from Navajo Nation planned their response 

collaboratively. Working with the TEC, 

CDC sent hantavirus experts to Navajo 

Nation to address concerns about the 

disease. Working with Tribal leaders 

across Tribal governance, CDC developed 

radio messages in Navajo, running daily 

for a month. A live radio call-in program 

brought Tribal leaders and CDC experts 

together to broadcast information across 

the Nation. The TEC hosted CDC experts who 

presented on both hantavirus and Zika virus. 

CDC shared national hantavirus registry data with the 

Navajo Epidemiology Center to help the center develop its own 

surveillance registry. The collaborative partnership between Navajo Nation and CDC 

continues to mature, and through the Hantavirus Exclusion Project, CDC plans to 

provide materials (such as wire mesh and expanding foam) to prevent rodents from 

entering homes or other buildings on Navajo Nation to combat hantavirus.

EPI Info is a critical field tool for 

epidemiologists to understand disease 

and risk factor trends and plot the course 

of a disease outbreak. A CDC Epi Info 

team member provided 27 hours of EPI 

Info training to the Rocky Mountain 

Tribal Epidemiology Center (RMTEC) in 

Billings, Montana. The training focused 

on data analysis with Visual Dashboard, 

creating electronic data collection forms, 

mapping data, and use of Android 

devices for data collection. Eighteen 

RMTEC and IHS public health workers 

participated in the training.

17
Yurok Tribe
pCDC’s Working Effectively with Tribal 

Governments is a cultural awareness training 

hosted by CDC University and offered to all CDC/

ATSDR staff. It provides an overview of legal 

foundations, American Indian and Alaska Native 

history, historical trauma, public health status, 

strategies to address public health problems, and 

best practices for engaging with American Indian 

and Alaska Native tribes and villages. The course 

is taught by American Indians and Alaska Natives 

along with CDC staff. To date, 250 CDC/ATSDR 

staff have participated in the course. 

pCDC’s HIV Prevention Program provides 

capacity building assistance (CBA) and resources 

to organizations and public health professionals 

implementing HIV prevention services. The 

assistance is provided at no cost through a 

national network of CBA providers, Prevention 

Training Centers, and other partners. In recent 

years, CDC has supported this assistance to 

organizations serving American Indians and 

Alaska Natives. CBA services include those 

related to human resource development, cultural 

competence, HIV testing and linkage to care, and 

organizational development.

pCDC’s Public Health Associate Program

(PHAP) is a competitive, 2-year, paid training 

program for recent college graduates with an 

interest in public health. PHAP associates are 

assigned to state, tribal, local, and territorial 

public health agencies and nongovernmental 

organizations and work alongside other 

professionals in a variety of public health 

settings. Throughout the training program, 

associates gain hands-on experience that will 

serve as a foundation for their public health 

careers. After completing the program, PHAP 

graduates are qualified to apply for jobs with 

public health agencies and organizations. Public 

health agencies and organizations compete to 

host a PHAP associate. Most recently, nine tribal 

host sites were matched with a PHAP associate, 

the largest number of PHAP associates assigned 

to a tribal host site in the history of the program.

PHAP Class, 2014 (FY 2015/16) 

1 Tribal Host Site

• Albuquerque Area Southwest Tribal 

Epidemiology Center 

PHAP Class, 2015 (FY 2016/2017) 

6 Tribal Host Sites 

• National Indian Health Board, Washington, DC 

• Southeast Alaska Regional Health Consortium, 

Juneau Medical Center, Juneau, AK 

• Alaska Native Tribal Health Consortium, 

Anchorage, AK

• Pascua Yaqui Tribe Health Services Division, 

Tucson, AZ 

• CDC/Indian Health Service, Albuquerque, NM 

• Great Lakes Inter-Tribal Council, 

Lac du Flambeau, WI

PHAP Class, 2016 (FY 2017/2018) 

9 Tribal Host Sites 

• Choctaw Health Center, Choctaw, MS 

• American Indian Cancer Foundation, 

Minneapolis, MN

• Manilaq Assocation, Kotzebue, AK

• Montana Department of Public Health, 

Helena, MT

• Rocky Mountain Tribal Epidemiology 

Center, Billings, MT 

• Southcentral Foundation, Anchorage, AK

• Indian Health Service, Rockville, MD 

• Indian Health Service, Albuquerque, NM 

• Eastern Band of Cherokee Indians, Public Health 

and Human Service Division, Cherokee, NC 

19
Taking the Health Pulse of 

Our Nation

CDC supports a broad range of surveys, 

surveillance systems, data collection and 

monitoring tools, disease and vital registries, 

and other efforts to ensure that we have our 

finger on the pulse of the nation. CDC tracks 

threats to health, the leading causes of 

death, how hard or easy it is to get health 

care, and differences in health across 

geographic regions and population groups. 

With the right information, CDC and public 

health professionals can take effective 

and timely actions to save lives and keep 

Americans secure. CDC uses the newest 

technologies and methods available, such 

as advanced molecular detection, to keep 

America’s public health system on the 

forefront of keeping people safe.

pCDC works with the IHS and TECs to 

strengthen data collection and analysis 

capabilities in support of the data needs of 

tribes. For example, CDC works with three TECs 

to improve the quantity and quality of injury 

reports available to American Indian and Alaska 

Native programs focused on reducing the 

health impact of intentional and unintentional 

injuries. The Albuquerque Area Southwest TEC, 

Navajo TEC, and Oklahoma City Area TEC are 

developing injury atlases, reports on opioid use 

and suicides, and an evaluation guide for traffic 

safety programs. Through this joint effort, 

CDC seeks to learn more about the magnitude, 

trends, and patterns of opioid use in Indian 

Country and support TECs in accessing and 

using data. With additional support from CDC, 

10 TECs and the Urban Indian Health Institute 

hone their surveillance and evaluation skills 

and expertise in support of tribes and tribal 

organizations implementing chronic disease 

prevention and health promotion programs.

pThe Navajo Birth Cohort Study (NBCS) is 

the first prospective epidemiologic study of 

pregnancy and neonatal outcomes in a uraniumexposed population. The purpose of the 

NBCS is to evaluate the potential association 

between environmental contaminants (such 

as uranium and other heavy metal exposures) 

and birth outcomes. A partnership with the 

Navajo Nation, the NBCS engages Navajo 

mothers, assesses their uranium exposure at 

key developmental milestones, and then follows 

their children to understand any associations 

between birth defects or developmental delays 

and maternal exposures. Study partners include 

ATSDR, University of New Mexico Community 

20
Environmental Health Program, Navajo Area 

Indian Health Service, Navajo Nation Division 

of Health, Navajo Nation Environmental 

Protection Agency, the Growing in Beauty 

Program, US EPA Region 9, and Navajo culture/

language specialists. Study partners include the 

University of New Mexico, Navajo Area Indian 

Health Service, and Navajo Nation Department 

of Health.

pCDC’s Pregnancy Risk Assessment 

Monitoring System (PRAMS) is a collaborative 

surveillance project that collects data on 

maternal attitudes and experiences before, 

during, and shortly after pregnancy. The 

PRAMS Tribal Flu Project was a 2-year initiative 

focused on American Indian mothers and their 

perceptions of and experiences with H1N1 

and seasonal influenza. Three states—New 

Mexico, Oregon, and Washington—worked 

collaboratively with tribes in a manner 

respecting tribal sovereignty, with the goal to 

establish or improve partnerships with tribes, 

increase participation by American Indian 

and Alaska Native women, and increase data 

sharing with tribes. The New Mexico PRAMS 

partnered with the Albuquerque Area TEC; 

the Navajo Epidemiology Center; the Tribal 

Women, Infants, and Children (WIC) Directors; 

and the Navajo area PRAMS to hire a permanent 

tribal liaison dedicated to maternal and child 

health issues. Washington partnered with the 

American Indian Health Commission, Northwest 

Portland Area Indian Health Board, and Seattle 

Indian Health Board to promote PRAMS and 

share influenza materials with tribes throughout 

the state. Interest and activities spread to other 

states, including a request from a tribe in North 

Carolina to share Washington’s printed influenza 

materials, and three states—Alaska, Michigan, 

and Wyoming— strengthened their PRAMS 

outreach to tribal communities. 

21
pCDC is working to improve the quality of 

surveillance data. A person’s race and ethnicity 

are often poorly captured on the nation’s data 

and surveillance systems, leading to a lower 

count of cancer cases or deaths or other events 

for some populations, including American 

Indians and Alaska Natives. By linking local, 

state, and national surveillance data with IHS 

patient registration data, many more events are 

“captured” as “belonging to” American Indians 

and Alaska Natives, which provides a much more 

accurate measure of the burden of disease and 

death among this population. 

pCDC and IHS work together to perform 

data links. In 2004, the IHS link to CDC’s 

National Program of Cancer Registries 

(NPCR) and the National Cancer Institute’s 

Surveillance, Epidemiology, and End Results 

(SEER) Program had results so significant that 

the link has become an annual central cancer 

registry requirement. These cancer registry 

links have resulted in the American Indian and 

Alaska Native Cancer Incidence Database, which 

provides what had been missing until now: 

more accurate data and analytic guidance for 

understanding cancer trends among American 

Indians and Alaska Natives. 

Klamath River 22
The success of the cancer registry links led 

to the IHS link with the National Death 

Index. This link resulted in the American 

Indian and Alaska Native Mortality 

Database, which provides more accurate 

information on mortality patterns among 

American Indians and Alaska Natives. 

These links have resulted in numerous 

publications sharing more accurate 

information about cancer incidence and 

mortality. For example:

• “Annual report to the nation on the status 

of cancer, 1975–2004, featuring cancer 

in American Indians and Alaska Natives.” 

Cancer. 2007;110(10):2119–2152.

• “An update on cancer in American Indians 

and Alaska Natives, 1999–2004.” Cancer. 

2008;113(suppl 5):1113–1273.

• American Indian and Alaska Native 

Mortality. A supplement to the American 

Journal of Public Health. 2014;104(suppl 3). 

pTribes may also undertake these data links, 

working with state health departments and 

tribal health directors. The Inter-Tribal Council 

of Michigan has been working with the Michigan 

Department of Health and Human Services on 

tribal links to cancer, birth, and death files in 

Michigan. CDC provided technical assistance 

and training on good link practices. The goal is to 

improve statewide data for American Indians and 

Alaska Natives in Michigan and tribe-specific data 

on cancer incidence, mortality, and natality for 

use by tribal health officials. 

pThe Oklahoma Area Indian Health Service

undertook its own data link, with assistance 

from CDC and working with the Oklahoma State 

Department of Health. Links to adjust for racial 

misclassification on Oklahoma death certificates 

were performed for years 2010–2015. Correction 

links were performed for years 2004–2009 to 

ensure that any changes or additions made 

since the initial link were incorporated into the 

data. Together, these actions found 4,417 death 

certificates that were not identified as American 

Indian or Alaska Native. The linked data set, 

capturing 26.6% more deaths, is available on the 

OK2Share website and will be used for planning, 

reporting, and projects within and outside IHS. 

pThe Haudenosaunee Nations, in adjacent 

territories in New York State, are the largest 

confederacy of related tribes in the East. The 

American Indian and Alaska Native Mortality 

Database, previously only used for national 

publications, provides an accurate picture of 

mortality for Haudenosaunee in New York State 

and will be used to develop and monitor effective 

interventions and strengthen health care services. 

This project is a collaboration of the Roswell Park 

Cancer Institute, CDC, the Mayo Clinic, and the 

Haudenosaunee Nations. 

San Carlos Apache Tribe

23
What’s Ahead?

For generations, tribal nations have 

implemented practices that protect and 

sustain the health and well-being of their 

people. Today, these practices are not widely 

understood by federal agencies and often not 

supported by federal grants and resources. 

At the request of its TAC, CDC hosted three 

convenings with a group of tribal leaders and 

members knowledgeable about tribal practices 

that promote physical, emotional, and spiritual 

well-being. The purpose of the convenings was to 

describe practices that would be appropriate for 

CDC to support with grant funding. With the help 

of the Healthy Native Communities Partnership, 

a national nonprofit organization working with 

Native communities to realize their own vision 

of wellness, the tribal leaders and members 

developed seven strategies and associated 

practices that promote the connection of mind, 

body, spirit, and community, and in this way 

promote health and well-being. CDC will use 

these seven strategies and associated practices 

in future funding opportunity announcements 

(FOAs) to support tribes and tribal organizations 

in implementing practices that keep people 

healthy and well. 

”

I was very happy with the convenings. 

I felt energy as soon as I entered the 

room. There was a circle with symbols 

in the middle of the room associated 

with different areas of life. The meeting 

was ours as Native People.

“

24
Short-term outcomes associated with 

the seven strategies:

• Increased participation in community 

wellness practices and events.

• Increased knowledge of tribal history 

and culture.

• Increased feelings of connectedness to 

and pride in cultural heritage.

• Increased consumption of traditional 

healthy foods and drinks.

• Increased opportunities to participate in 

physical activity and increased participation 

in physical activity opportunities.

• Increased understanding of and 

engagement in healthy living practices 

by community members.

• Increased understanding of one’s spiritual, 

mental, and physical well-being.

Seven Strategies that Promote Health and Well-Being

1. Family and community activities that 

connect cultural teachings to health 

and wellness.

2. Seasonal cultural and traditional 

practices that support health and 

wellness.

3. Social and cultural activities that 

promote community wellness.

4. Tribal, intertribal, governmental, and 

nongovernmental collaborations that 

strengthen well-being.

5. Intergenerational learning opportunities 

that support well-being and resilience.

6. Cultural teachings and practices about 

traditional healthy foods to promote 

health, sustenance, and sustainability.

7. Traditional and contemporary physical 

activities that strengthen well-being.

25
”

It was something special to be there

[at the convenings]; I always hear back 

home that there is hardly a consideration 

for Native healing in the meetings they 

attend—they are all about Western 

methodology, focused on the pain, and 

that doesn’t always work for us. There 

is misunderstanding of the practices of 

Natives, so we’re often on the negative 

side. The tribal convenings were 

geared toward having the government 

understand. Some traditional practices are 

difficult to measure in the way that things 

are measured, but there needs to be trust 

that we know what we’re doing.

“

26
Pendleton gift from Confederated Tribes of the Colville Reservation 27
Tribal Advisory Committee Meeting Locations

• Winter 2010–2016: Atlanta, GA 

• Summer 2010: Havre, MT 

Hosts: Fort Belknap Indian Community 

• Summer 2011: Portland, OR 

Hosts: Northwest Portland Area Indian Health 

Board, Quileute Tribe 

• Summer 2012: Uncasville, CT

Hosts: Mohegan Tribe of Indians

• Summer 2014: Acme, Michigan

Hosts: Bemidji Area Tribes 

• Summer 2015: Spokane, WA

Hosts: Confederated Tribes of the Colville 

Reservation, Kalispel Tribe of Indians 

• Summer 2016: Valley Center, CA

Hosts: La Jolla Band of Luiseño Indians 

Listening Session Locations

• 2014: Billings, MT 

• 2015: Rancho Mirage, CA

• 2016: Atlanta, GA 

CDC Leadership Visits

2012 

• Oglala Sioux Tribe, Pine Ridge, SD 

• Cherokee Nation, Tahhequah, OK 

• Duwamish Tribe, Seattle, WA 

• Suqamish Tribe, Suqamish, WA 

2013 

• Tohono O’oodham Nation, Papago, AZ

• Tlingit Tribe, Sitka and Kake, AK 

2014

• Northern Cheyenne Tribe, Lame Deer, MT 

• Arapaho and Shoshone Tribes, Wind River, WY 

2015

• Poarch Band of Creek Indians, Atmore, AL 

• Confederated Tribes of the Colville Reservation, Coulee Dam, WA 

• Spokane Tribe of Indians, Wellpinit, WA 

• Kalispel Tribe of Indians, Spokane, WA 

• Tulalip Tribes, Tulalip, WA 

• Eastern Band of Cherokee Indians, Cherokee, NC 

• Mississippi Band of Choctaw Indians, Choctaw, MS 

• Sault Ste. Marie Band of Chippewa Indians, Sault Ste. Marie, MI 

2016

• Navajo Nation, Window Rock, AZ

• Hopi Tribe, Kykotsmovi Village, AZ

• Cochiti Pueblo, Cochiti, NM 

• Turtle Mountain Band of Chippewa Indians, Belcourt, ND 

• La Jolla Band of Luiseño Indians, Pauma Valley, CA 

• Gila River Indian Community, Sacaton, AZ

• Confederate Tribes of the Umatilla Reservation, Pendleton, OR

CDC Visits in Indian Country: 

A Snapshot

28
CDC leadership visits 

to Indian Country 

have nearly doubled 

since 2012. “”

29
30
Kasha-Katuwe Tent Rocks National Monument 31